Laserfiche WebLink
❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Anderson Barngrover Ranch <br /> Site Address City State ZIP <br /> 14290 E. Comstock Road Linden CA 95236 <br /> APN Supervisor District <br /> 091-030-130 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel M Other <br /> Requested Operating Permit <br /> Comments <br /> Workplan Review for Groundwater Monitoring Well Installation —; <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facijity�ontact ❑Property Owner ❑Contractor p Architect <br /> required see below see below see�e ow see below see below n/a <br /> I$Billing Party f{]Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Archlted <br /> FDavide Last name If contractor,indicate type and license number <br /> Taylor <br /> Address City State ZIP <br /> Anderson Barn rover Ranch, 1997 Calusa Trail Middleburg— FL 32086-8210 <br /> Phone Phone Email <br /> (209) 351-0124 davidt@abwalnut..com <br /> ❑Billing Party ❑Facility Owner M Facility Contact ❑Property Owner ®Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Joe Brusca <br /> CEG#1948 <br /> Address ZIP <br /> Brusca Associates,Inc., PO Box 332 Roseville CA 95661 <br /> 916 677-1470 Phone JEmail <br /> ( ) (916) 204-8434 ibrusca@bruscaas,;ociates.com <br /> ❑Billing Parry ❑Facility Owner ❑Facility Contact CRProperty Owner ❑Contractor ❑Architect <br /> First Name L st mna e If contractor,indicate type and license number <br /> Tim §aSado <br /> Address City State ZIP <br /> 16461 E. Comstock Road Linden CA 95236 <br /> Phone Phone Email <br /> (phone <br /> ) 931-2568 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or busines owner,operator or authorized agent of same,acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges asso ated with this projector activity will be billed tome or my business as identified on this <br /> form. <br /> I also certify that I have prepared a on an h to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDE _ <br /> APPLICANT'S 51GNATURE: DATE: Z5 <br /> *I PROPERTY/BUSINESS OWNER ❑OPERATOR/ ANAGER ❑OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned T � Linked FA ID �` <br /> Date Z/ PE ^ #I D 3- Fee Record Number <br /> ❑Cash 7 �Che(c'k St Confirmation N Payment <br /> Received By <br /> Rev 07/10/2024 <br />